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published the address which so far has formed the subject of
my text. After bestowing a few complimentary remarks on the
address the article goes on to say : ^^ Unfortunately, several Euro-
pean authorities of high repute continually advocate extreme



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896 pbaequb: i8 bo-oallbd oonsebvatism in gtmeooloot

courses, such as total extirpation of the uterus with the appen-
dages in cases of chronic, or even acute, inflammatorj affections
of the tube and ovary. Last June the German Gynecological
Association met at Vienna. A leading authority laid down the
law that in gonorrheal disease of the appendages it is absolutely
wrong to leave the tube and ovary on one side, even if they
seem healthy, and that it is much better to remove the uterus as
well. Another authority supported him on the score that many
* parenchymatous bleeding areas ' are to be found in the uterus
in these cases, so he always removes that organ. He does the
same, he adds, in cases of malignant ovarian tumor— a clini-
cal and pathological condition quite different from gonorrheal
inflammation. Veit, of Berlin, spoke in a vein of satire. The
advocates of amputation of the uterus insist that when the
appendages alone are removed, exudations on the two pediclea
set up pain and cause adhesions to the intestine or else fix
the uterus. Veit attributes the exudations to fresh gonor-
rheal infection ; therefore, says he, ' castration of the husband
is the best thing for the patient.' Unfortunately, in France as
well as in Germany, hysterectomy is extensively carried out. It
is diflScult to conceive anything more unsurgical than extirpa-
tion of the internal female organs for damage done by gonor*
rhea."

I think it will be conceded that there is a large proportion of
cases in which, in the interest of the patient's future well-being,
it is advisable when removing the ovaries and tubes to remove
the uterus also.

The modern method of excision of the breast demands the
complete removal of the axillary glands, the fascia, and the skin
beyond any suspicious line of infection ; and is it not probable
that in removing the adnexa for malignant disease it is wise alsa
to extirpate the uterus, which would otherwise, at best, be but
a useless organ, especially when we consider that its removal
adds little if any to the danger of the operation ? Is it not
easy to understand also that there must be a certain number of
cases in which the uterus is found to be so diseased (when the
abdomen has in the first instance been opened for the extirpa-
tion of diseased appendages) as to make it advisable, in the inte-
rest of the patient, to sacrifice that also ?

Although a great many contend that it should invariably be
removed at the same time as the ovaries and tubes, because



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OOKDUOIVE OF THE BEST RESULTS TO THE PAT!

withoat them it is a useless organ, I think it is nc
with correct principles to remove an unoffending c
because it is useless. Yet, according to the Brit
Journal^ this course has the advocacy of many autho]
repute, and therefore it should not receive wholesal
tion until it is proved beyond the shadow of doubt
logical authorities are either less educated or more
both, than their brethren in the other branches.

The sentence, however, that I find hardest to re
pathological fact is that containing the startling sti
^^ it is difScuIt to conceive anything more unsurgical
tion of the internal female organs for damage done b^

When so flat-footed a statement as this is made
me that we are entitled to ask the writer — whose v
least coincide with those of the editorial staff, o
article would not have been admitted as a " leaders-
knows anything about the damage to the internal f<
caused by gonorrhea, and, if so, what treatment s
tion is in the majority of cases of the slightest avail

This is a fair sample of so-called ^^conservative
Those who have had to deal with internal female
aged by gonorrhea know that delay here, in the la
tion of cases, means death and a harvest for the un

If the writer is aware of any plan of dealing witl
condition which will at the same time preserve t
her organs and her life, he should not lose time i
the fact, that his confreres will no longer be under
of indulging in the unsurgical (?) course which 1:
hard to understand.

I do not wish to be understood as advocating
mutilation of the human or other animal, but w
organs threaten life or place the patient in such a
life becomes a burden, or prevent the performance
sary duties, I can imagine no higher privilege thai
surgeon to remove the offending members and re
tient to a condition of safety or usefulness.

While in the greatest number of instances the
guidance undoubtedly is that the least sacrifice o;
exhibition of the best surgery, in malignant dif
other hand, it is better to "cut wide of the mark.''

The removal of ovaries and tubes simply for pai
57



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898 PBAEOBs: IS so-called oonsbbyatism in gtneoolooy

do not present pathological conditions, has for some time been
condemned by gynecologists, and there is no more occasion for
members of the general body of the profession to keep harping
on that string than there is for the gynecologist to keep on re-
minding the ophthalmic snrgeon that the eye is a valnable organ
and should not be wantonly condemned simply because it is
nnsightly or sightless and no source of danger to the other eye.
I imagine it would be found, if an exhaustive inquiry were
made into the matter, that the neurotic cases, those in which the
patient " carries her sexual apparatus on her brain,'' do not re-
main in the hands of the gynecologist after it becomes appa>
rent that the sexual organs are not the seat of disease, but are
handed over, as they should be, to the neurologist.

Having indulged in this long introduction, let me briefly in-
quire what so-called conservatism does for the female from an
early period of her existence. In the first place, while it raises
its voice loudly against operative measures having cnre for their
object, it appears to take no stock in prevention, and has done
nothing to lift the veil of ignorance, mock-modesty, or whatever
you choose to call it, which covers the whole subject of the phy-
siology of the sexual apparatus.

It almost necessarily follows that the young, about the time of
puberty (if their minds have not already received the " evil com-
munication " which, we are told, "corrupts good manners"), get
anything but strictly trustworthy physiological facte about their
functions from those who neither in knowledge nor years are
fit or capable to impart information which, properly given,
would be useful and in a great many instances really preven-
tive.

Does the young expectant mother, as a rule, receive from the
medical practitioner the information that would be so useful to
her during the time of her pregnancy?

• Is it not a fact that too often she is left to obtain information,
which may or may not be trustworthy, from more or less igno-
rant females whose only qualification, as a rule, is that ** they
have been through the mill " ?

How often does it happen, in spite of all that has been writ-
ten as to the importance of repairing damage to the perineum
immediately after the completion of delivery, that any attention
is given to that body, on the integrity of which a woman's com^
fort and future well-being so largely depend?



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OONDUOIVB OF THE BEST BBSULT8 TO THE PATIENT? 899

Or if it is stitched, how inach value can be attached to the
manner in which it is done in too many cases — for is it not a
fact that too often the woman gets up with only a skin peri-
neum, one existing in name only, and anatomically not of the
slightest practical valne to her ?

Then, some few months or weeks after, when she complains
of more or less backache, bearing-down pain, pelvic distress, or
purulent discharge, how often is she submitted to strictly scien-
tific treatment ?

Is it not of such frequency that it may almost be stated as
the rule that she is given some supposed tonic and vaginal
wash, and that without adequate directions as to use, and as-
sured that as she gets stronger she will lose her symptoms!

And the last state of that woman becoming worse than the
first, she eventually does what she should have done long ago and
falls into the hands of a gynecologist, who restores her to soci-
ety a useful member. The great reward bestowed on the gyne-
cologist is the charge of having operated needlessly.

While it has not been proved with mathematical accu-
racy that laceration of the cervix is the cause of cancer, is it
not a fact that in the greater number of cases of cancer the
cervix is found lacerated, and may not the unhealthy tissue
thereby induced be more prone to take on malignant degenera-
tion!

Or granting, for the sake of argument, that there is no rela-
• tionship between laceration and cancer, is there any vah*d rea^
son why an injury of the cervix should not be repaired by
suturing in precisely the same manner that the general surgeon
would adopt in a wound of the lip, or forearm, or any other
part of the body! Why attempt to get primary union in one
part of the body and teach that it is wrong in another! What
would be thought of the surgeon who took so little pains in
approximating the edges of a wound in a woman's face that an
ugly scar was the result? Beyond the fact of the annoyance
caused by the unsightly scar in this situation, the cicatricial tis-
sue would not in all probability cause or set up any suffering,
and yet fault is found with us for trying to prevent a mass of
soar tissue in the cervix where it undoubtedly is often produc-
tive of a neurosis.

In commencing malignancy of the uterus does not so-called
conservatism in delaying operation or in only removing a small



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900 HA.MILL : A OASB OF AOQUIBBD ATRESIA OF THE VAOUIA.

aud insigai Scant portion of the cervix condemn the patient to
an almost certain recurrence and death ?

Trae conservatism recommends the removal of the whole or-
gan earljy with bat little risk to life and at the expense of a
body whose functions are already lost in consequence of the
disease.

So long as we hold fast to sargical principles and apply them
to our gynecological patients, I think we can make sure of keep-
ing on the right track, and instead of being put on the defen-
sive we are entitled to ask of all our critics and of all cavillerB-^
and we shall require something more than mere assertions from
them^Is so-called conservatism in gynecology conducive of the
best results to the patient }



A CASE OP ACQUIRED ATRESIA OF THE VAGINA. '



BOBEBT H. HAMILL, M.D.,
Philadelphia.



While atresia of the vagina is by no means an uncommon
condition, I feel that there is sufficient interest attached to the
following case to bear recording. The origin of the atresia in
this case is one that we are not likely to meet with often.

M. 0., aged 35 years, the mother of four children, came under
my care at the Philadelphia Hospital last May. Her last child
was born August 12th, 1891, and the labor was a normal one.
The perineum was lacerated. She was attended by two medical
students, who repaired the perineum at once. The stitches were
introduced one and a half inches in the vagina, uniting the ante-
rior and posterior walls, thus causing the atresia. She remained
in bed two weeks. In February, 1895, the child died, since the
birth of which, up to the time of her admisrion to the hospital,
she had not menstruated. Before the child's death she had suf-
fered no inconvenience, but soon after she noticed that about
every fourth week she had paroxysms of pain in the lower part
of her abdomen, becoming worse each successive month, and

■ Read before the Section oa Gynecology, College of Physicians of Philadal-
phia.



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HAMILL: a 0A8B OF AOQUIRBD ATRESIA OF THB VAGINA. 901

being of a sharp, catting character. These pains were always
accompanied with nausea and vomiting. In the latter part of
April she noticed the presence of a tnmor in the lower part of
the abdomen, which was very tender to the touch. It was diffi-
cult to secure any movement of the bowels, and when they were
moved it was always accompanied with intense pain. An ex-
amination revealed a slight median perineal tear, and the vagina
was closed one and a half inches from the vulva. A cicatricial
band was seen across the vagina, and there was a slight area of
ulceration. Rectal examination revealed the pelvis filled with
a dense fluctuating mass about the size of a cocoanut, and bi-
manual examination showed on the left side an oblong tumor,
about as large as a good -sized cucumber, filling the left iliac
region. On the right the pelvis was entirely filled with the
large mass detected by the examination per rectum. The dia-
gnosis of hematocolpos and hematometra was made, and a sup-
posed hematosalpinx. On May 22d, 1895, an exploratory inci-
sion was made for the hematosalpinx on the left side, which
proved to be a distended uterus pushed over by the hemato-
colpos and filled with blood. An opening was made in the
va^na with bluut-pointed scissors, and there escaped about one
and a half quarts of a thick, grumous, brownish-black blood,
being retained menstrual secretions, from the vagina and uterus.
The cavities were thoroughly irrigated with bichloride solution
and packed with iodoform gauze, the vagina being packed daily
and douched with sterile water. Convalescence was uneventful,
with the exception of a papular eruption on the thighs and legs,
which rapidly disappeared when sterile gauze was used in the
place of iodoform.

It has been a question in my mind as to whether it was wise
or not to have subjected my patient to the additional dangers
attendant upon an exploratory incision ; but thinking, as I did,
that I had to deal with a hematosalpinx, I felt that it was wise
to adopt the procedure which I did. I had in mind at the time
a case which I had seen where hematosalpinx existed with he-
matometra and the uterus was emptied through the vagina.
Shortly after this operation a leakage from the tubes caused a
peritonitis which resulted in the woman's death. Had a hemato-
salpinx existed in my case I might have had a similar expe-
rience, and, as an exploratory incision is of minor importance
as regards the danger of death, I feel that I was warranted in



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902 mR8T: 0A8B OF ACQUIRED ATRESIA OF THE TAGIVA.

doing the section, particularly as my patient has had no unfaTor-
able symptoms since. When she left the hospital, which was
a number of weeks after the operation, the vagina had shown
no disposition to unite again. The woman was instmcted to
report to me if such a condition arose, and, as I have not heard
from her up to the present time, it is fair to presume that there
has not been a closure.

The atresia following labor is usually connected with some
complication of the labor itself. Neugebauer * has collected
one h^ndred and seventy-six cases of acquired atresia of the
vagina of puerperal origin, and in the vast majority of them it
was connected with complications of labor.

I should be pleased to have the opinion of the Fellows in rela-
tion to the advisability of making an exploratory incision when
there is doubt as to the existence of hematosalpinx. In this
particular case to make a positive diagnosis was practically
impossible, as, owing to the immense size of the hematocolpos,
I was unable to distinctly map out the nterine appendages.

844 South ISth street.



A REMARKABLE CASE OF ACQUIRED ATRESIA 07 THE

VAOINA.«



BARTON COOKE HIRST, M.D.



The case about to be reported possesses some features in its
etiology and treatment which are, I think, unique. In &e
comprehensive statistics just collected and published by Neuge-
baner * there is nothing exactly like it.

^sina was delivered of her first child in July, 1892.

She states that a woman physician in charge of the confinemeDt
'' cut her and then sewed her up again.'' A year later another

' " Zur Lehre von den angeborenen und erworbenen Yerwachsungen und
Yerengerungen der Scheide/' etc. , Berlin, 1895. (One hundred and aeyenty-flii
cases.)

» Read before the Section on Gynecology, CoUege of Physicians of Philt-
delphia.

'"Zur Lehre von den angebOTenen und erworbenen Yenraohsongen nod
Yerengerungen der Scheide/' et^, Berlhi, 1895. (One thousand oases.)



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HIB8T : 0A8B OF AOQUIBED AT&SSIA OF THB YAOUNA. 903

womao piiyBician did two operations apon her vagina, the Da^
tare of which the patient does not know. A month or two later
she fell into the hands of a gynecologist, who removed both of
lier ovaries. As it appeared later, this gynecologist must have
operated on her without making a vaginal examination. In the
following spring the woman was conscious of a swelling in the
lower abdomen and suffered great pain. A few months later
there was a suddeu discharge of a large quantity of bloody fluid
from the urethra (rupture of a hematocolpos into the bladder),
whereupon the pain and swelling disappeared. These symp-
toms, however, reappeared, and in the following winter (Decem-
ber, 1894) my friend Dr. Edward Martin, whom the patient
consulted, found an atresia of the vagina at its upper third, and
in the line of atresia a row of silver sutures that must have been
there since July, 1398.

The sutures were removed and the hematocolpos opened, but
in doing this a vesico- vaginal fistula was established. In a short
time the vagina closed again completely, but the vesico-vaginal
fistula persisted. Two attempts were made to close the fistula,
without success. In the meantime there had been again a col-
lection of menstrual discharge in the vagina with a reappearance
of the old symptoms. It was found impossible to tap this col-
lection through the vagina, or to reopen the vagina without en-
larging the vesico-vagiual fistula and endangering the ureters.
An attempt was therefore made by Dr. Lain6, in Dr. Martin's
absence, to evacuate the fluid by a puncture through the rec-
tum. This succeeded, but the vagina refilled rapidly and the
woman became quite seriously ill, with high fever, a hectic flush
upon her cheeks, prostration, and rapid loss of weight. In this
condition she was put under my care in the Howard Hospital.

On examination I found a large vesico-vaginal fistula, an
atresia of the vagina in its upper third, with extreme cicatricial
contraction, and, as the result of ulceration, a mere bridge of
connective tissue separating bladder and rectum. Above the
point of atresia there could be felt by rectal and abdominal ex-
amination a cystic tumor which was extremely sensitive. In
view of the repeated failures to keep the vagina open, and on
account of the likelihood of injuring both bladder and rec-
tum in an attempt to make the opening large enough for a per-
manently successful result, I determined to perform hysterec-
tomy as the surest means of preventing a reaccumulation of fluid



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904 MANTON : BOOALLED PUEBPEBAL K0LAMP8IA

aboTe the poiDt of vaginal closure. This was done fonr months
ago. I found that a portion of one ovary remained from the
last abdominal operation, explaining the persistence of menstm-
ation. As I cut off the womb a fountain of pus gushed from
the cervical canal and deluged the pelvic peritoneum. The
latter was cleansed by the dry method and the cavity closed
without drainage. The layer of connective tissne joining blad-
der and rectum and obliterating the vagrina was then punc-
tured, and the purulent fluid remaining in the vagina evacu-
ated. The woman made a good recovery. I have recently
closed the vesico-vaginal fistula successfully, and the patient is
now perfectly well.

Appended is the list of ten operations by six physicians to
which this patient was subjected before she was cured :

Operation on the vagina during labor (Dr. G.) ; two plastic
operations in the vagina (Dr. F.) ; a salpingo- oophorectomy
(Dr. P.); operation for atresia of the vagina (Dr. M.); two
nnsuceessful operations on a vesico-vaginal fistula (Dr. li.);
puncture of the hematocolpos through the rectum (Dr. L.);
hysterectomy and discission of the vagina (Dr. H.) ; operation on
vesico-vaginal fistula (Dr. H.).

1821 Spruce strebt.

SO CALLED PUERPERAL ECLAMPSIA IN ITS RELATION TO

INSANITY."



BT

W. P. MANTON, M.D.,

Ckxiiulting Oyneoolofftst to the Bastern and Noithero Michiiiran Aayhiint for the Idmum

and St. Joseph's Retreat; ProfesBor of CUnical QynecoloRy and Lecturer on Obstetrics*

Detroit College of ttedicine; (^gynecologist to Harper Hospital ; Vice-President

Medical Board, Detroit Woman's Hospital, etc, etc,

Detroit, Mich.



There is a tendency on the part of most of ns to accept foreign
statistics, especially those coming from Germany, as represent-
ing unqualifiedly the status of any given condition in this coun-
try, as well as in the country from which such statistics have
emanated. The differences in the habits of life, the modifica-
tions due to environment, and the constitution of the peoples of
other nations are either overlooked or ignored, and the results

* Read before the American Association of Obstetricians and Qyneoologists,
September, 1895.



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IN ITS BBLATION TO INSANITY. 905

of investigatioDS abroad credited as obtainiog id the same degree
in like conditions in the New World as in the Old. While
foreign statistics of disease are exceedingly important and valu-
able to ns in many ways, I am convinced that they are often
misleading as regards corresponding conditions in onr own
country, and hence shonld be more generally looked npon as
local contributions only to the snm total of onr knowledge of
a given subject.

Some four years ago, in an able and elaborate paper by 01s-
hausen on the puerperal psychoses, with especial reference to
insanity as a sequel of eclampsia,' a greater importance was
given to the latter disorder than the experience of the majority
of American observers would seem to warrant. In the follow-
ing brief communication I have summed up the results of my
own researches in this matter, and I believe that, for this coun-
try at least, the figures presented represent more correctly the
connection between the two disorders than do those of the
authority referred to.

An attempt to establish a relationship between two morbid
somatic affections, the one acting as cause, the other appearing
as effect, presupposes a knowledge of the etiology of the excit-
ing agent. Of so-called puerperal eclampsia ae a factor in the
production of insanity this cannot be claimed ; for, while the
literaturo of this disorder is voluminous, our actual knowledge
as to its origin is still indefinite and unsatisfactory, and any
effort to trace the connection between the two diseases by argu-
ments based on the various theories and hypotheses which have
already been advanced as to its etiology must inevitably lead to
disappointment and confusion.

In discussing the relationship of these two conditions, there-
fore, we must acknowledge our ignorance concerning the pri-
mary etiological factors concerned in the production of eclamp-
sia, and attempt the solution of the question of its bearing on
insanity by confining our attention to the investigation of such
facts as may be at our disposal.

According to the latest statistics to which I have had access,
those of Bidder,* in 60,583 deliveries eclampsia occurred 455
times, or once in about 133 labors. Of this number 79, or 17.3

> Zeitschrlft fOr Geburtahcafe und Gynftkologie, Bd. zxi., Hi ii., p. 871,
1891.
• Aichiv ftlr Gynftkologie, Bd. zliv., 1898, p. 165.



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1



906 MANTON : PUEBPBBAL ECLAMPSIA AND INSANITT.

percent, proved fatal ; bat as 31 of the women died of complicat-
ing disorders — sepsis and pneumonia — only 48, or 10.6 per cent,
can be said to bare saccumbed to the convnlsive attacks. These
figures are mach lower than those given by Goldberg,* who re-
cords a mortality of 24.7 per cent. Accepting Bidder's 10.5 per
cent as the lowest mortality, we have left 89.6 per cent of
eclamptic women to be accounted for as cured, that is, as recov-
ered from the immediate effects of the convulsive disorder. Wt
are informed by obstetrical writers, however, that, while recov-
ery from the primary disease may take place, other conditions,
notably insanity, may follow in its wake ; and as the original



Online LibrarySpringerLink (Online service)The American journal of obstetrics and diseases of women and children → online text (page 86 of 95)